'The Impact of Language on Social and Communication Functioning in Children with Cochlear

'The Impact of Language on Social and Communication Functioning in Children with Cochlear Implants' EHDI 2015 March 10, 2015 9:40 a.m. to 10:10 a.m. (EST)

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>>: Good morning. There are two topics presented this morning in this room. The first is 'The Impact of Language on Social and Communication Functioning in Children with Cochlear Implants'. I would like to ask you to take a moment to silence yourself is or other electronics and please return the evaluation form when you Lee. Thank you. S>> SUSAN WILEY: All right. Thank you for coming. I have a big group of co-authors who are really a team of folks at children's who helped us with this work and I guess I wanted to step back a little bit and describe our pathway to our we are focusing on what we are focusing on. We some time ago, we were focusing more on kids who are deaf plus, so those who are not learning typically. And as we understood that group better, to get more dollars, we started having to have comparison groups. We have had the premise at our institution that when we look at how kids are doing, we should not necessarily particularly compare them to deaf kids but development only peers. Some of the work is in that area, but as we understood more, we are finding some things in the kids who are cognitively average or above. Some of this talk, this group of kids we are studying includes kids of all, not all, but a variety of range of capabilities, but with a little bit more of a focus on what you will see as our findings are the bit more striking in kids with higher skills. So thinking about why do we think about social and communication skills, clearly when we are intervening for kids, the goal is really interaction, communication, and functioning in society. So really, the skills, the language maybe a foundation for the skills, but we need to be focusing on that goal as well. And unfortunately, for kids who are deaf/hard of hearing, a lot of research on possible skills are functional listening or functional hearing. You will see measures of functional performance used in audiology but a little less so in the broader domains. So we just felt like we needed to look a little more in depth. So these talks are the backwards. I am sorry. They just put them backward. I like to talk about the language first and get to the social communication. There will be some overlap, but for this project to talk we wanted to see how language level impact social and communication functioning in children with Cochlear Implants. Our framework for this is your language level, is a lower than your cognitive abilities and how does that affect daily functional skills? We will often see a lot of studies in the language realm, but they don't really take into consideration a child's capabilities and where they fall on Dr. Cement skis big curve of Baltimore out layers. Our initial outlay are, we have a large study on kids with any degree of bilateral hearing loss who are three to six years of age, have bilateral sensorineural hearing loss and hearing loss is prelingual and we were okay with kids having a nonverbal IQ of anything 40 and about. This has quite a range and interestingly, when we look at groupings with kids as we describe of average capability and below, for whatever reason they actually wind up pretty nicely on degree of hearing loss and age. So the assessment tools we use included a number of things. The Preschool Language Scale 5, that is a pretty normal stool. It may not be the perfect tool. Some people don't like it as much, but it gives at least some scores we can use in an analysis and if a child uses sign, which, we did use a sonic which interpreter. So we would give them an oral language first and then follow up with sign language. We also did, under cognitive battery, with the Leiter International Performance Scale R revised and some parent measures of executive functioning. And are functional assessment were two tools. One was Vineland Adaptive Behavior Scales, which is probably more commonly recognized particularly was psychologist, but there is also a tool called Pediatric Evaluation of Disability Inventory and this is an inventory that is a parent report. Both of these are based on. Reports and talk about capabilities in functional domains. The PEDI only goes to an age of seven. So just to give it a little bit more information, on that PEDI, with Mr. This, there is a trained research personnel who can help a family if there are not certain, but there is 197 discrete items they answer. You may not get to the top and the domains are in self-care, mobility, and social function. What it does is it gives more of a T score and 50 is the being rather than 100. This is a rehabilitation to think about treatment planning and identify need areas where there is assistance. There is also a caregiver form that goes with that to kind of understand the needs by the caregiver, meeting for example, if a child has mobility in a community, but can get around in a wheelchair, that is taken into consideration. Or I can dress myself, but I need verbal prompts and that is taken into consideration. We did not use the aspect of the tool, but it is helpful an understanding where a child's needs are and how to move to the next level. On the social bunch of domain, which is what we are going to focus on today, there is a lot of overlap with language, but it is distinctly different. There are issues around comprehension of boards and meanings, but we are also looking at social interactive play with adults. Interaction with children of similar ages, how do kids play, how do they participate in household chores and community functioning. It goes beyond the usual language realm. This is an example of a family who answered; it doesn't happen or happens reasonably often. You can see place with activities or games that have rules, plays cooperative he with others. You can see while these are not necessarily always notable on language assessment. And then the Vineland is a common tool. It has the domains of communication, daily living, socialization, and motor skills and that they actually give domain standard scores in those different domains. You could look at adaptive behavior in different subgroups as well as a composite. So what are we even talking about we talk about a language gap? This is different than some of the definitions you may have seen. I have seen people talk about gap wideners or gap closers, but really it is about are you commensurate with your capabilities or your nonverbal IQs. We looked at a language to cognitive ratio. This is not the perfect ratio. It is the best we can come up with, but ratios are as good of standard scores, but we really kind of wanted to convey how far you are all from your potential. We calculate that with the receptive language standard score over the nonverbal IQ score. So for example, if you have a language score of 80 and a nonverbal IQ of 100, your language gap would be.80. You are 80% -- you are hitting 80% of your potential, right. So that is your definition. We can argue whether that is good or bad, and I think the other thing when you think about this is the gap -- because this definition is labeled this way; the gap in lower scores may be less. So for example, if your IQ is 40, how low would your quotient go? It is not going to go below zero. There is a bias in how we do that. But interestingly, in our kids, over 50% had a language to cognitive ratio of less than 80. More than half of the kids in our group are not hitting their cognitive Mark. What do our kids look like? These are the kids with Cochlear Implants. We have 41 kids with implants. This group, as I said, they were three to 6 year olds. At this age, the average study was 58 months. Interestingly again, I don't know how this happened, but we had a pretty equal division of 3 year olds, for year olds, and 5 year olds. I don't know how that happened. It is really lucked. On average kids have had their implant for at least 31 months and half of them received a bilateral implant. Four were simultaneous. When we look at other demographics, half of them, others, have at least a college degree. And 41% used public insurance. We kind of have a well-educated subgroup and they we have folks who are more likely needing some public insurance. 50% up and was reported a total household income to be below $50,000 a year and 20% were living at or below the poverty level. It is not a perfect distribution, but it is there. So when we look at how our functional skills are doing, so this is the Vineland on the left and the PEDI on the right. What we are hoping for its skills at that 100 level. That would be the average. So if we take -- is this the new normal -- but our kids are underperforming in all of the domains of the Vineland and on the PEDI as well. So what we are going to focus on today is the communication aspect of the Vineland and the social functioning on the PEDI. This is just another -- actually this is rapidly a slightly duplicative slide. This is the comparison. I did want to throw the kids with hearing aids in here just to give a sense, a comparison of implant users and hearing aid users. Interestingly, most everybody in this study were pretty well amplified. So when we looked at analysis, degree of hearing loss, it was not actually impacting outcomes. So they are reasonably comparable in their performance. So what was important? So when we looked at the factors that impacted social communication, what was striking is we looked at our receptive, receptive language score to IQ quotient. And that really did convey a fair amount of variance and impact on our outcome. What was also striking is the nonverbal IQ also impacted this. This is not a total surprise. We would think with a better IQ, our language is going to be a little bit higher. And we will see in the next talk that there is a little bit of a reverse correlation. Both for the Vineland and the PEDI, our nonverbal IQ did move us in a good direction to improve outcomes. All right. This is a little busy of a slide as well. This is a PEDI social functioning. This time what we did is we made -- we converted it to a score of 100. We converted 50 to -- 100. No matter what their cognitive potential was, we had kids who were in the low, which area and kids who were on average -- not average -- this is not an average score. This is there commensurate. So your average, your IQ are pretty much aligned. Am I making sense? This feels like this is confusing. A few of the kids are beating the potential; their social functioning skill is looking pretty good. Kids with gaps, their social functioning is really and a markedly delayed area. So we break that out further across the regions. So if we have kids whose IQ are over 90 -- these are 95 -- these are the kids who are perceived as higher functioning kids -- we see that there language is commensurate -- I'm trying to get my marker -- their social functioning score looks much better and above average. That is what you would hope to see. But those kids who have a normal or high average IQ with a language gap are functioning at a much lower keep ability that they ought to be. This kind of plays out further with the lower IQ group. So as you break it down into different segments of IQ, we continue to see better performance for those kids who have the commensurate language than those who have that gap. And that our low IQ kids also have, if they are commensurate, they are in the low average or borderline range. If they have a gap, they are struggling even more. What is struggling is when we look at these gap kids, we can see that kids who have a high IQ with a gap function similar to the lower IQ without a gap. And we also see that they are not too far off from kids with what would be an intellectual disability who do not have a gap. So that makes us think well, how are we missing the boat? Very similar results on the Vineland. So again, we have our total group and they we have our range of IQs. When we looked at this data between implant users and hearing aid users, the results are pretty similar. Again, we see in our total group, those kids with a more commensurate language cognitive capability. There Vineland communication score, their functional communication is reasonably along with their capabilities and then as we move up, or as we get those gaps in these different groups of higher IQ, midrange IQ and lower IQ, we see that same kind of gap. Not quite as much in the low average group. So we recognize that our low language performance really impacts social communication. And interestingly this doesn't have to be, it doesn't have to be sub normal. These are kids with scores in the average range of this. They would not be identified as having a need through their standard scores. They would not be identify through the school districts as being behind and I think we really have to think differently about how we understand where kids should be and try to meet their potential and kind of recognize that when we don't hit that, we are going to have sub optimal social communication. And when we looked at some of our group last year and looked at what are some of the therapy and communication goals, often the pragmatics and language and social skills are really missing or nearly nonexistent. And yes, you have to have like, which to get there, so it is not that language is not an important foundation, but we really need to think about how do we intervene differently for pragmatic and social skills. I would say that EI services and schools may actually be much better locations to think about pragmatics than clinical settings when it is an adult and a kid working on things. So what do we kind of, say? We do think anchorages directly related to the social communication functioning and this gap has a negative impact. It is easy to be complacent about low, low/normal, or low language scores. When you think about it that has been a great advance of early detection and intervention. We are getting kids to almost average. We are saying that is not good enough and we want to shoot higher. We also started looking at kids who are from birth to three years all. We want to keep looking at them to understand the impact down the road, but we also recognize this gap is already happening at three to six. What is happening at younger ages? We are fortunate to get money to look at birth to three years all. This is tricky as well, but we have got kids of all ages. On the bottom we have the age in the month and then on this axis, we have the ratio. So language to cognition. Again, we are shooting. We are hoping for 1. It is great if you are above the line. That major language is superseding your nonverbal problem solving. That is not a problem. But interestingly the number of kids who are at these lower -- the kids with gaps -- the gap does not seem to be widening with age. Again, this is cross sectional so it is not the same kid over time, but we have kids who are -- I kind of went ahead -- but there are kids who have gaps at older ages and kids who have gaps at younger ages. But when we look at the social functioning, that is where we do see a social impact -- sorry -- we do see an impact on age. As kids get older, the social functioning actually -- we are seeing more deficits and more challenges in the social functioning with the increasing age. And so that was on the PEDI. This is the same thing on the Vineland. On the Vineland it is not quite as striking as the PEDI. They do measure things differently, and it may be that the Vineland is more linked to language, things at earlier ages and hits though social functioning a little bit later. On the Vineland we are not seeing quite the same relationship. So one of the things we are trying -- and let me check my time -- I think we are not too bad -- we are actually piloting -- we have kind of said what we are doing isn't working. Can be try something else? We have no idea if this is going to work, but this is a curious question. Sandra Grether, who does a lot with augmentative communication, I felt the kids who are learning differently are not processing in a way that we are presenting it. So we thought augmentative technology may be a strategy. Clinically we have seen in kids who learn language differently, sometimes aud/com is the key to jumpstart that next start. So we may see kids who have apraxia or other language problems, but because it is static and you can process it visually, there can be some explosions in language. We thought why does it matter if you have a disorder, if you just have a gap? Would that methodology perhaps help? We have started a very small pilot study with kids who have been in our larger study with a language gap and are doing an iPad study where they had this word power software. And at this point we can actually lockdown the iPad for other interventions or other apps. We can measure how people are measuring it. Are you measuring it at home? What is happening is we have had a pre evaluation. We get a language sample and look at what they are doing. It is a very traditional augmentative communication approach. So in our city generally, what we have try to do is six weeks of intervention with the device, send you home for six weeks for practice, and bring you back for another six weeks of boosters. That is the process we are following and we are hopefully going to see changes pre to post intervention. We are looking at syntax, grammar, and length of utterance. We have kids who are enrolled and I think they are in week 2 or week 3. And even hearing the feedback already, one kid has an average nonverbal IQ and the other had a below average nonverbal IQ and you might think they would perform differently but both very quickly within one session figured out what they needed to do to communicate and use the device. This is not to replace speech or sign; it is to build your language. The idea is we help build the right syntax and grammar and building your sentences along complexity. And with one child, the kid -- well, actually both had more speech production even within the session. So from the beginning of the session to the end of the session, there was more speech production. And increase sentence length and grammar with the kid with the average IQ. The kid that was lower, would you think are you going to learned this quickly? Actually, they saw changes very quickly. We are hopeful that this may be a new approach. We know the old approaches does not seem to be closing the gap. Is there some other way? Technology is here. It is not a replacement for communication. What I find is sometimes even if you talk about this with families or therapists, it feels like a step back and in reality it could be the step forward and it is not replacing our other modalities. I would like to thank a great team of research personnel, boys town has helped us with some of this as well and we have recruited and enrolled separatist up its for us and then the families we have had have been exceptional. We have some time for some questions if you have questions. The iPad study, we are looking at anybody that was in the original study, I think the kids -- we were; we are starting with the kids we know who are three to six. I think our kids are four to six. I mean, this is really exploratory, but I think we just have to shake it up a little bit and figure out what might work. IPads are pretty universal at this. So we are using word power -- I think it is word power as the app. Word power software. One of the reasons -- and I am not a speech like was pathologist, but their thought process was you could really build grammar and that has been one of the areas where we are seeing a lot of challenges. So I think we want to get a little more -- we want to understand a little better if this is going to work, but I don't know if this is going to be a distinct age cut off except no screen time before two. That this is not really screen time. This is a tool to help language development. In the back? (Comment off mic). S>>: SUSAN WILEY I could not hear all the questions. The kids who are signing versus oral? Really there were not differences in communication modality. There were not differences in amount of therapy. I mean, we looked at a number of things. And the language stuff has a little bit more that embedded. But things we would normally think matter, didn't. I am starting to wonder are these gap kids -- is there a proportion of them who actually have a language impairment or some other issue that is hard to identify early? But all of these kids were early identified. So they had the benefit -- even the hearing aid group versus the implant group had about an equal duration of amplification. The hearing aid group would have been effectively amplified earlier than the CI kids and I think that confers a little bit of benefit, but really we did not see modality. We did not see type of intervention. We did not see school placement play out. There is quite an extensive questionnaire on different things in therapy. Whether private, you know school based therapy, hours in therapy, oddly, sadly that did not confer any benefit. Sorry. (Comment off mic). >> JANE FREUTEL: The question was as a teacher of the deaf, she sees kids who fit this profile, and are there interventions or strategies to close the gap? The hard part is we have understood the gap at this point. We are trying to explore strategies. I think there would be folks in the room who can answer that more effectively in terms of intervention. I think partly it is recognizing we need to teach some of these skills as well -- we are focusing on the language and we are forgetting that we have to play with others. We have to take turns. All of that theory of mind stuff and trying to get that in and yes, it is very linked to language. If you cannot process it, it is hard to recognize those things. But just like you do any kid, when you read a book talk about the why and not just the what, labeled as a do this -- but why did that person do that? Why do you think that is going to happen? Not as an educator or a therapist, I feel a little -- even the technology intervention really is intended to hit the language. You are absolutely right. But we also recognize the need to do some improved social interaction. Again, I say schools are more primed for that, playgroups. If you are and EI, do you join a playgroup and that is your natural environment where you work to facilitate and help families facilitate those interactions? Does anybody have any good ideas to guide? No one? (Laughter). Practice. How do we teach kids to do it? We first play with adults and you think I don't want to lose all the time. You have your 3 year old or 4 year old -- if I let you win all the time -- I don't want to let you play anymore. You have to win sometimes. I don't know. (Comment off mic). >> JANE FREUTEL: Yes. (Comment off mic). >> JANE FREUTEL: So her comment was really focusing on the social skills in duos or trios and putting that in your plan. I think there are challenges academically. When you switch to academic situations, social skills are not the goal. I mean, they are -- isn't that what school teaches us more than academics. I cannot tell you what I learned in fourth grade academically, but I can tell you when I fell on the playground. I think one of the groups of kids who are pushing that agenda more, kids with high functioning autism, so you could do well academically, but socially you are not. But IDA does not require that. Schools are not measured on our ability -- the kindergarten rules -- playing in the sandbox and so forth. Other questions? All right. If you want to head out -- to switch off -- I won't feel bad -- I promise. And I am sorry to say -- no, that is the wrong one. There is a little bit of overlap. We might get done early this way. I need to switch my notes. Hang on with me. Okay. This presentation is really focusing more on the language and we will get a better sense of the broader group.

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